Chronic Pain Opioid Guidelines for People with Active Addiction, People in Recovery and People on MAT

Pain management for people with substance use disorders or
addiction histories is tricky business.

People with substance use disorders or addiction histories
often experience chronic pain (for example, up to 60% of people with opioid
addictions report chronic pain.)1

Though opioid drugs provide strong analgesia, people with
active addiction or addictive histories are at higher risk of drug-misuse and
addiction. For this reason, many people in recovery feel reluctant to use
opioids for pain management and many doctors feel reluctant to prescribe
opioids to people with addiction or addiction history issues.

However, uncontrolled pain is a significant risk factor for
relapse or worsened substance use.

So if you’ve got pain and addiction/addiction history, you
may feel like you’re between a rock and a hard place - what should you do?

Well, to help you with this, read over the opioid use
guidelines from SAMHSA for people with active addiction, people in recovery and
people on methadone or Suboxone. These
guidelines take you step-by-step from low-risk pain management strategies all
the way to opioid use (if needed). By following these guidelines and by
observing safe opioid use practices, you can reduce your risk of opioid misuse
and addiction while still keeping all pain-management strategies on the table.

If this combination of non-opioids and non-pharmacological
treatment results in sufficient pain relief, stop here and do not continue on
to opioid use. If analgesia isn’t sufficient, consider whether the benefits of
opioid use outweigh the risks, and they do, start an opioid trial.

If opioids don’t cause a substantial improvement in pain,
quality of life or functioning, then wean off and continue with other
therapies. If opioids result in significant improvements, continue with them
while monitoring to make certain that positive results continue (pain
relief may diminish over time) and while monitoring for adverse effects, like
addiction.

Opioid Guidelines for Methadone and Suboxone Users

Consider increasing the methadone or Suboxone dose for improved
pain-relief. At the same time, begin non-pharmacological pain treatments,
physical and occupational therapy and mental
health and wellness treatments.

If pain relief remains inadequate and if the benefits of
opioids outweigh the risks, begin an opioid trial (opioids in conjunction with methadone therapy).

Because at sufficient doses, methadone blocks the euphoria of supplementary opioids, a person can use opioids for pain while on methadone without getting high and without losing control over their use.

Opioid Guidelines – People with Active Addiction

Opioids are rarely an appropriate chronic pain treatment
for people with an active drug or alcohol use disorder. If someone with active addiction requires
chronic pain treatment, the steps are:

Start addiction treatment. Do not use opioids yet. If you
are abusing opioids, either start tapering off or continue to use under the close
direction of an addiction professional while receiving addiction treatment.

Once stabilized and in recovery, continue with the pain
management steps outlined above, within the ‘in recovery’ guidelines.

Reducing Opioid Risks

If you and your doctor feel opioids are necessary despite an
elevated risk for addiction, you can safeguard against problems by taking
precautionary measures to reduce your risks. Examples of precautionary measures
include:

Agreeing to a program of urine testing (which checks for
drug misuse)

Agreeing to frequent visit intervals and small
prescriptions.

Agreeing to have family members or others from your support
network involved – these people can be entrusted with keeping the supply and
handing medications on schedule and monitoring for signs of abuse.

Using opioids with less rewarding properties (such as
codeine or tramadol) rather than more potent opioids like oxycodone.